We have decided to publish a book on the best of our mental illness blogs over the past 4 and a bit years. The book will be available in print and e-book formats everywhere in early 2019.

Below is the introduction:

We began this blog in October 2014 in order to provide commentary on the state of mental illness and its treatment for the lay public. What we provide is a viewpoint from that of a psychiatrist with many years of experience (David Laing Dawson) and a family member of someone who does have schizophrenia (Marvin Ross). Aside from his personal experience (or lived experience as it is commonly referred to), he is also a medical writer, advocate and publisher of books that take a unique look at mental illness.

To date, we have had close to 75,000 views and have been read in 151 different countries since 2014.

We also write on other topics but these are the ones on mental illness covering topics like recovery, treatments, suicide, addictions, and alternative treatments (or pseudo science).

When we began, we had this to say of our purpose:

Welcome to the launch of Mind You. While we intend to post on mental illness,mental health and life, we decided on the name Mind You to reflect that not everything is black and white. There are ideas and opinions but then mind you, on the other hand, one can say…….

And that is what we would like to reflect. Ideas about mental illness,health and life that can be debated and discussed so that we can come to a higher understanding of the issues. And, we have separated out mental illness from mental health because, despite their often interchangeability, they are distinct.

The National Alliance on Mental Illness defines mental illness as a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder.

On the other hand, the World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. That is quite different from mental illness.

Unfortunately there is a tendency to confuse these and organizations like the Mental Health Commission of Canada have a tendency to talk about mental health issues and problems which are not the same as mental illnesses.

Both Dr David Laing Dawson and I (Marvin Ross) will be posting on a regular basis on a variety of topics.

The posts we have selected for this volume are the most widely read over the past 4 years.

For mental health workers: Stop asking the suicide question. It is a question that produces about 50% false positive, 49% genuine negative, and 1% false negative answers. It misleads and distracts. And, clearly, even with thousands of mental health professionals asking that question over and over again, the actual completed suicide rate is increasing (it does not work), while the statement “I want to die” has become legitimized as a replacement for, “I am not happy with my life at this moment.”

The question also distracts and misleads. The answer to this simple question becomes the criteria for holding or not holding, for acting or not acting, for caring or not caring. It also, in hospitals and emergency rooms, becomes a cover-my-ass question before discharging from care.

Rather, spend the time to be with. To look, listen, and attend. Depression is visible. It is not a hidden illness. It is visible. If you don’t believe me watch Anthony Bourdain’s last television special.

Agitated Depression, a combination of despair and high anxiety, is very visible and a high risk for suicide. The pain of agitated depression is hard to sit with, be next to. The diminution of conscious awareness is apparent. Being there and listening one can experience the loss of attachment to others and to a future and to the pain of being in that person’s skin.

Flat, blunted depression is airless. The eyes have no life, the voice no lilt; the entire arousal system is diminished. It is difficult to sit long with this person without feeling his or her lonely shrinking consciousness.

Offer help and treatment in a safe environment. And by treatment I mean medical psychiatric treatment, not a CBT course starting next month. Hospitalization is needed if the risk is severe, and definitely when the person is in a state of agitated depression, or if he or she not once in the course of an hour spoke of anything beyond tomorrow, and no one’s name caused a glimmer of light to appear in his eyes.

Offer treatment, help, hope and hospitalization. Severely depressed people accept help when it is offered.

Do not “contract for safety”. It is, again, a bizarre “cover-my-ass” approach that is obviously paradoxical. It means, at face value, that the counselor believes the risk of suicide is high and at the same time that eliciting a promise to not kill oneself (at least before the next appointment) is a sufficient response to that risk.

This week, after the suicides of three Ontario Provincial Police officers a heartfelt plea went out from the president of the Union. He implored officers who were suffering to seek help, to talk with someone.

A similar heartfelt message was re posted by my daughter after she learned an old friend had committed suicide.

Broadly, over the last many years, we have seen many “Let’s talk about it” public campaigns.

But over those same years the numbers of completed suicides have gradually increased while the numbers of people taken to the emergency departments for assessment of “suicide ideation” have dramatically increased.

What are we missing?

I think it is this: Most suicides are the product of severe depression. Not all, but most. And often complicated by loss, drugs, alcohol, pain, anxiety, poverty, PTSD, bullying. But still, usually, a state of depression.

And depression, medical depression, is not simply a mood disorder. It is a cognitive disorder as well. Let me explain.

Normally, when we are healthy, our consciousness includes much more than ourselves. Besides being aware of ourselves and our inner state we are aware of (conscious of) our surroundings, the task at hand, our loved ones, our extended family, our colleagues, our friends, our fellow travelers, the citizens of our community, of our country, and, sometimes, far beyond that. All of these things and people float in and out of our consciousness through the waking hours, and may visit us as an eternal puzzle in our dreams.

I assume that awareness, the breadth of that awareness, varies from person to person. For most of us it does not that often go beyond friends, workmates and family, fellow travelers, until we watch the news. Still, it always stretches beyond ourselves.

Not in a severe depression. In a medical depression, the illness depression, our consciousness shrivels. That floating awareness of all around us closes in. We, when suffering from a depression, lose our awareness of others. They simply fall away from our consciousness.

Hence asking a severely depressed person to reach out to others is akin to asking a paralyzed man to walk to the nearest emergency.

The public anti suicide programs and initiatives may even be making the problem worse. They reduce this mental health problem to a dichotomy: thinking about suicide or not thinking about suicide, held in hospital or not held in hospital.

Certainly the statistics tell us the current public initiatives are not working. Not working.

A far better approach would be to talk about depression. Recognizing it in ourselves and others, and helping those others seek treatment. We do have effective treatment for depression.

At our best we carry in our heads a sense of the thoughts and feelings and wellness of others as well as our own. I am not talking about empathy here but rather that a piece of our consciousness is devoted to the existence of others; that an awareness of others, even when they are not present, is an important part of consciousness.

This ability allows us to experience empathy but it is wider than that. When conscious, at our best, we are aware of not just what we see and hear and of ourselves, but of the people in our lives and our connections to them. And that circle of people can include a few family members or stretch to the refugees of South Sudan.

At our best.

In a psychotic illness that awareness can become strangely distorted, with one or many of these relationships over interpreted, imbued with magical power or ominous threat. This is easy to observe, from a stated conclusion that the people on television talk to me or the police are watching me and putting drugs in my orange juice.

What is not so easy to observe is the effect of clinical depression. But depression, the illness depression, diminishes and eventually eliminates that social form of consciousness; the awareness of others, our connections to them, the presence they maintain in our minds, is lost in depression. Consciousness, in depression, is reduced to simply the self, and the self in depression is a malfunctioning body of limited worth and a sense of dread. Others are gone from our shrinking cloud of consciousness.

Anthony Bourdain killed himself in a hotel room in Paris and I watched CNN last night. He left grieving friends, colleagues, fans, and an eleven year-old daughter. Oddly, with what I have written above, Anthony made a career out of connecting with, engaging with others and sharing their lives and cuisines.

Apart from remembering, paying tribute to Anthony Bourdain last night, much of the focus was on suicide. The number of a suicide hot line was displayed throughout. But we have had these help lines available for 30 years and, as CNN reported, the suicide rate continues to climb. And as I recounted in a previous blog, the numbers of people brought to emergency rooms for assessment of “suicide ideation” has been growing by 14 percent year after year. Yet actual numbers of completed suicides persist and grow.

The focus on suicide itself is wrong. This focus, this de-stigmatization and “talk about it” approach obviously has not helped and may even be a contributing factor.

Suicide is the product of despair, dread, pain, anxiety coupled with the cognitive impairment of depression I have described above. It is this cognitive impairment that allows the severely depressed person to not realize the damage his death by suicide will do to his daughter or son, sister, brother.

We are often bewildered by seemingly successful people with loving partners and family who kill themselves. But depression, the illness depression, renders success hollow, and gradually eliminates loved ones from consciousness. In depression one’s sphere of consciousness has deflated to the agony of self. And at that point we seldom call a hot line or seek out help.

For prevention of suicide we need to focus on depression. The recognition of depression and the cognitive deficit that develops with depression, and the treatment of depression.

Much of psychiatry is about convincing people to do things that will improve their mood, their health, and their lives. Exercise, better diet, overcoming fears, taking necessary medication, stop taking harmful substances, go to bed earlier, turn off electronics, find balance in your life, join something to overcome loneliness, stop procrastinating, call a relative, tell your husband, plan your day, stop worrying about things you cannot control, take baby steps, take medication regularly as prescribed, go for blood tests, enjoy small pleasures, scream at someone rather than cut yourself….

It is not in the DSM V (I think) but we know “no man is an island”. We are social beings. Maybe not to the extent of bees and ants, but no less than chimpanzees. We are never fully independent life forms. Even a hermit has a relationship (albeit a distorted and contrary one) with the community and family he or she is rejecting.

We also know that the quick impulse to say to the doctor, “Don’t tell my family.” or “I don’t want my family involved.” is often derived from shame, guilt, a sense of failure, and sometimes the opposite, a genuine wish to not burden the other. This is further complicated in the teen and youth years by an ongoing negotiation with respect to power, control, individuation, responsibility. We also know in these years the adolescent often says, in the same breath, “I hate you. Give me a hug.” “Get out of my life. Drive me to the mall.” “Don’t tell my dad. Please tell my dad so he can protect me.”

And we also know that persons suffering from severe anxiety and depression develop a sort of tunnel vision that excludes broad levels of social awareness and understanding. “Leave me alone.” And people suffering from a psychotic illness often harbour delusions about family members. “She’s controlling me.”

So, absolutely, when the young person says, “Don’t involve my family.” professionals should explore this, and then convince the patient otherwise unless there is good evidence that keeping the family (parents, sibs) away will be ultimately better for this patient.

One of the constant themes in my writing of mental illness is the need to involve the family. And so, when I read a lengthy account of the suicide of a young 20 year old girl that appeared in my local paper, what jumped out at me was that she had requested that her family not be involved with her illness or treatment. She wanted to spare the family grief and, it seems that the doctors went along with her.

The young girl had a number of suicide attempts while in hospital and the family was told none of it. Dr Peter Cook, one of the psychiatrists, told the newspaper that “We were obligated to protect the privacy of Nicole. She was an adult.” The other shrink said that confidentiality between patient and doctor is “sacrosanct.” Nicole did not want to share her medical information with her family.

Sadly, this young lady is not the only suicide in the past little while at this hospital. There have been 9 – 3 in hospital, 2 of patients on leave and 4 outpatients. To its credit, the hospital did commission an external review to see if things could be improved. One of the recommendations was for “closer collaboration with families.”

Now, maybe the outcome would not have been different if the family was involved but we don’t know that. And, the privacy legislation is pretty confining but there are ways to get around them if the medical staff really care. The hospital recently established a family resource centre as the result of a donation from a philanthropist friend of mine. It was difficult to get them to accept the gift but they did and it is being used and it is being well publicized to families.

At the time we were negotiating for a family resource centre at the hospital, I wrote an op ed for the local paper on the need that families have for inclusion with staff when their loved ones are being treated. Aside from pointing out the anger that families have towards being ignored, I mentioned the very sensible guidelines that were produced by the Mental Health Commission of Canada for family caregiver inclusion. And I mentioned this:

“Very few, if any, mental health facilities have adopted these recommendations despite the fact that about 70 per cent of those with serious mental illness live with their families according to the Mood Disorders study. And family caregivers spend 27 hours a week caring for their ill relative according to the EUFAMI survey. That is five hours longer than the average in other countries surveyed by EUFAMI.”

I don’t know if St Joes ever did adopt these recommendations and I do know that the Privacy Act is very restrictive. But, with a little effort, it can be sidestepped as I pointed out in a Huffington Post Blog.

I was basing what I had to say on an excellent paper on the topic that had recently been published by Dr. Richard O’Reilly, a professor of psychiatry, Dr. John Gray, an adjunct professor of psychiatry along with J. Jung, a student in the Faculty of Health Science at Western University.

I said this in my post:

They point out that clinicians often don’t even bother to ask their patients if they have permission to involve family.

If they do and the patient refuses, then they should take the time to explore the reasons for this refusal. Many patients don’t understand why it is important and do agree to allow their families information once it is explained to them. In some cases, there is some information they do not want shared (like sexual activity and/or drug use) and the staff can ensure that this information is not shared. Staff can also inform families of pertinent facts in meetings with the patient present. This often allays patient fears and is similar to the approach recommended in the UK and by the Mental Health Commission of Canada.

In those cases where no consent is given, the staff can give general information to the families and receive vital information from the family. The family can tell the doctors about new emerging symptoms, worsening of symptoms and medication side effects, all of which should be crucial information.

Until such time as political jurisdictions reform the privacy legislation, mental health staff can do far more to open the channels of communication with families for the betterment of their patients. It is time they do so.

I was pleasantly surprised that at a meeting with St Joes staff just after this was published, one of them told me that this blog was being read by staff and was being circulated within the hospital.

It seems that not sufficient attention may have been paid to that. I hope that more attention is paid to involving families so that these tragic events can be minimized going forward.

All that I have written in parts I, II, III and IV apply to this population as well. But the overall rate of suicide on some reserves is tragically high.

There are several factors that lower the threshold for suicide. Some of these, I think, are inherent in the dependent and isolated nature of reserves and the impossible cultural stew that one finds on these reserves.

Many years ago, even before the internet, I was walking through Kenora in Northern Ontario one evening when I saw three boys practicing break dancing on an empty lot. They were first nations kids with a boom box, possibly from the White Dog reserve. If so, these were boys who lived on a reserve two hours north of Kenora in the wilderness and they had adopted a dance form that originated on the street corners of the South Bronx within the African American and Hispanic community.

In that same time period a shaman invited me to attend an exorcism he was soon going to perform on a woman possessed by an evil spirit. He suggested I bring some holy water with me for protection. When I asked him why he wanted me there, he answered, “You might bring some of those pills of yours.” So here we have native spiritualism, an Ojibway healing ceremony, Catholic holy water to guard against evil, and anti-psychotic medication just in case.

Another man I saw because his son was in jail explained to me that within his culture children were not raised with the kinds of discipline and control that people of European descent expect. They run free within the village.

At the time I suggested that might have worked well a hundred years ago, but now with alcohol, drugs, firearms, television, cell phones, internet….

I thought of the cliché that “It takes a village to raise a child.” And I can well imagine a village of First Nations People raising a successful child one hundred, maybe five hundred years ago, the boys learning skills and being inducted into the hunting and warrior cultures of the men, the coming of age ceremonies, the girls learning skills and being inducted into the world of women, of gathering, sewing and cooking, of childbirth and babies.

I attended a band council meeting on one occasion to discuss the problem of their teens and youth getting in so much trouble. They constituted a high percentage of the population of the Kenora jail. During the meeting one councilor said he almost wished that they could still send their teenagers off to residential school to learn some discipline. He went on to say it is the parents’ fault. The kids roam the village at night, out of control, looking for drugs or alcohol or trouble or excitement.

It is easy to see why the threshold for violence and suicide is low. The structure, rituals and meaning of growing up in a hunting gathering village have been lost, and the structure, meaning, rituals, rules, organization, expectations of an industrial society (or even a post-industrial society) have never quite taken. The first has been lost (or badly damaged by my ancestors, by politicians, the church, the merchants) despite attempts to hold onto language and rituals. The second never quite accepted. An elected band council is superimposed over a traditional tribal politic. Survival now depends on negotiations for food and housing, clean water and medicine with two levels of Government, not on hunting, gathering, planting, building, making, preserving.

Caught in this the teenagers easily become lost. Many now see little future for themselves. Or to put it another way, it is especially hard for a teenager living in a small, isolated northern community to imagine a bright and satisfying future for himself or herself in a larger world, a larger world that is very visible to them on television. The threshold for suicide pacts, for the contagion of suicide, and for a lethal impulsive action is much lower.

We can fly in mental health resources, improve the local school, try a number of different programs to help youth in those communities, but ultimately I think this will continue unless and until we find a way of ending the reserve system. This kind of chronic dependency is not good for anyone, least of all teenagers.

Or we could study the successful reserves, of which there are a few. And by we I mean government, first nation leaders and organizations. Can this be replicated elsewhere? Is it possible to retain and preserve these ancient cultures and languages without creating an artificial existence and a pathological hostile dependency?

A native friend once told me when we were working together that there were no swear words in Anishinabek languages. Then, on an evening when I was having dinner with a chief, I asked him, the chief that is, what he and his people would say when they were angry.

He smiled slyly and answered, “You must remember that the Indian had no reason to be angry before the white man came.”

As I write this a third 12 year old has killed herself on a small isolated Ontario Reserve. The photo of her in the newspaper shows a sweet child standing before a decorated Christmas tree, a large ginger bread man, and an enormous candy cane. She is clearly within puberty at this early age, and she smiles with innocence and charm. There is talk of money, of mental health workers, of safety plans for the tweens and teens of this two thousand person community.

But this is a band aid on a slow hemorrhage. Our system of reserves is a trap. It is a pretense at preserving a way of life, a culture. It works for those on the payroll, and perhaps for those whose jobs entail preserving and teaching the traditions and languages, and representing their people. But the children and teens? Netflix, a ginger bread man, a Christmas tree and a totem, clothes and packaged food from the stores, alcohol and drugs, video games, occasional attendance at school, and long winters with little to do.

I don’t have a solution. But I do know some advice for leadership applies equally well for the parents of children and teens: “Give them purpose. If you can’t give them purpose give them hope. And, above all else, keep them busy.”

Juliette is shy of her 14th birthday and Romeo perhaps 16. Shakespeare knew this tragedy would not play had these “star-crossed lovers” been much older.

The brain has not fully developed until age 22 to 25. Yet the years before that involve an intense social learning curve, a testing out and practicing, competing, comparing, shunning and sharing. The prizes are belonging, achieving, competence, prominence, intimacy, self-esteem and sex.

Our brains are also uniquely forward looking. We listen and scan for the minute and hour and day to come. We perceive and select from our environment information that informs us of what is coming. Even when we retrieve memory we shape it for tomorrow. We reform, reinvent the memory to serve our needs for today and tomorrow.

It is no surprise to me that when I ask a teenager what really happened at school yesterday or last week they respond with at least three versions that support their wishes for tomorrow, with total disregard for logical narrative. I have to fill in the blanks to get the true story, or at least a plausible facsimile.

And as teenagers they have limited perspective, limited sense of a world beyond themselves, limited sense of the many years and experiences to come. They live in the now, anticipating only tomorrow. Only a teenager could mouth the words, “If I’m not invited to the prom my life is over.”

And today teenagers live within this cauldron of social competition 12 to 20 hours per day every day of the week. Even when they reject it, as some do, they are defining themselves by rejecting their peers.

So, along with the risks for suicide listed in Part II teenagers also pose the risk of concluding – on the basis of what we adults know is a temporary setback but they see as life defining – that they should kill themselves: the posted naked picture, the rumour at school, the rejection, the betrayal, the public or gossiped accusation….

As I was writing this a Washington Post article popped up on my Blackberry Passport. A girl in the US is on trial for manslaughter. She had encouraged her boyfriend to kill himself through a flurry of texts. When he was parked in his pickup truck filling with carbon monoxide he stepped out and texted her. He wasn’t sure. He had second thoughts. She told him to get back in. This he did. She was 17 when she explained to him that a better life awaited him in heaven.

Apart from anti-bullying initiatives are there ways we can reduce this risk unique to teenagers and youth? Maybe.

Ensure they have reprieve from the adolescent peer cauldron. Electronics off by 9 pm at the very least. Holidays totally away from this. Family time without electronics. More of their time with peers spent in supervised skill building activities.

Know what is happening in your child’s bedroom.

Know what is being posted on your child’s facebook and instagram account.

Know what they are texting to one another. At least check on it occasionally.

Never, ever let them have access to lethal weapons. And there are times a car or a truck can be considered a lethal weapon.

Understand what I have written above about the adolescent brain.

And for teenage and youth counselors, therapists, psychiatrists and family doctors. Please, please, always see these kids with a parent. Make the time you see a kid without a parent an exception for a good reason. Not the kid’s reason, but a good adult reason. And the only good adult reason for not having a parent present is that you have seen the parent(s) and he or she is hopelessly drunk, violent, stupid, immature or in jail.

You see, it is seldom you (therapist, counselor) who can provide an alternative reality to a teenager drowning in his peer group, at least not for much more than an hour a week. But a parent might be able to with some encouragement, instruction, and advice. Just simply having a parent in that consulting room with his or her son or daughter may empower a parent to be a parent, may assign responsibility where it really belongs, and open the window for a teenager to see that there is an adult world with a broader and longer perspective.

At least every second night on television I can watch an ad for a pharmaceutical during which a calm mesmerizing voice tells me of all the possible side effects of the drug being promoted. It is a voice playing over reassuring music and a pastoral video. Often, for a certain class of drugs, the warnings include “may cause suicidal ideation in teens and youth.”

The SSRI medications (from Paxil to Zoloft) come with the same warning and patients going on these medications are cautioned to watch for “suicidal thoughts”.

This is nonsense, of course.

If we had actually found a drug that, when taken, could instill a specific thought, the CIA would be all over it.

Pharmaceuticals can affect our arousal systems, heightening or dampening; they can affect our physiological sensations; they can affect our energy levels, our pain, our comfort, our ability to think clearly; but they do not instill specific thoughts. The very idea is ludicrous. Even the ingestion of mescaline or LSD requires specific anticipation, context and guidance in order to provoke either ecstasy or horror.

There is a history of how those warnings came to be, and political and legal reasons for drug companies to continue them.

When these warnings were first published and doctors in those small northern European countries (that keep complete and excellent national data) stopped prescribing these medications for depressed younger people, the actual suicide rate over the following ten years went up in that population. So most physicians went back to prescribing these along with the caution to “watch for suicidal thoughts”.

But there is something very instructive in all of this. We are social beings. How we think, how we express our thinking, how we react, how we negotiate with each other, the language we use to express our unhappiness or anger – these are all socially and culturally determined. We learn what works and we use it. We are highly impressionable. Especially when we are young.

So it is not surprising that with the dramatic increase in public awareness of, and the exhortations to watch for suicidal ideation, both the experience of and the reporting of a “suicidal thought” have dramatically increased.

People are routinely asked that question on surveys, on screens for depression used in family doctor’s offices, on psychological testing and in most encounters with a mental health care professional. The question is asked of most distressed people.

SSRI medication is prescribed for people who have been at least identified as being distressed and the question of suicide ideation has been asked of them. In some cases, often.

As a medical test used for an assessment of risk of suicide, the question, “Are you experiencing suicidal thoughts?” (in whatever form it is asked), now yields about 95% false positives. All clinicians know that it also yields about 1 or 2% false negatives.

The truth is many people who answer yes to a variant of that question are brought to emergency (see charts in part I). In the emergency department they are assessed in various ways. And they are allowed to leave when their answer to that question reverts to “No.”

At that point they are often asked to “contract for safety”. This is a particularly silly intervention and amounts to the patient being allowed to leave after he or she has promised to not hurt themselves.

This has caused several obvious and a few less obvious problems.

With the emphasis on that question, the actual cause or nature of the person’s distress may be missed entirely: e.g. relationship distress, abuse, anger, anxiety, guilt, teen drama, need for parenting, fear, loss, grief……

Misuse of relatively scarce medical resources.

Support for and reinforcement of the “suicide threat” as being a legitimate way to negotiate with others.

The emphasis shifts from patient care to safeguards against legal liability.

Unnecessary admissions to hospital of people whose answers don’t revert to “No.” until they have been on the inpatient ward for a few days.

Reliance on that question produces the 1 to 2% false negatives who should have been kept in hospital and treated, not because they said yes or no to that particular question, but because they were agitated, psychotic, or severely depressed, and truly at high risk.

With mental health workers, nurses, doctors, so focused on people expressing “suicidal ideation” they can miss far more important indicators of high risk.

Finally, some people experience suicidal thoughts not because they are suicidal, but as specific obsessive thinking, and sometimes, as an intrusive or unbidden thought, and sometimes as an inserted thought, experienced as being put in one’s head. This thought can take the linguistic form of either, “I should kill myself.” Or “You should kill yourself.” The thought itself is distressing to the patient. In the case of this being an obsessive thought torturing someone with OCD, it is not an indicator of high risk of suicide. But it is treatable with the same drugs and counseling that work with other OCD symptoms.

When the thought is experienced as being put in one’s head, and as a command, it does indicate risk, as well as psychosis. It is a symptom of a psychotic illness requiring treatment. However this person is unlikely to answer yes on a screen for “suicidal ideation”. It is a command hallucination that this patient will only admit to experiencing, reluctantly, within a longer, slower, quieter interview.

I know I can’t, but I would like to ask all clinicians and counselors to stop asking the suicide question, at least not as routine, not as a survey. It is not preventing actual suicide.

The problem with a public campaign to prevent suicides by identifying suicide ideation is that it is akin to a public campaign to prevent heart failure. Both actual heart failure and actual suicide are end stages of other processes, but in the case of heart failure we know enough to target cardiovascular disease, obesity, hypertension, diabetes, smoking, rather than “heart failure”. We do not say, “Call this number if your heart is failing.”

It is not a perfect analogy but one can imagine what would happen if we established dedicated phone lines across the country to respond specifically to people who felt “their hearts were failing”. And then what would happen if each of these callers were instructed to go to an emergency department.

Curiously the authors of the original article that surrounds the four graphs I included in Part 1 of this series, summarize by emphasizing the importance of identifying suicidal ideation and going to the emergency department for assessment. More of the same. Stay the course. Double down.

We do not easily give up our cherished beliefs. And as with many human endeavours, it is often politically and personally more important to appear to be doing something about a problem than to actually do something effective.

We know the demographics of completed suicide. We know the risk factors. We know the specific and sometimes treatable illnesses that all too frequently lead to suicide. So if we truly want to reduce the actual numbers of people who kill themselves (not threats, small overdoses, passing considerations), then we need to stop wasting resources on “suicide prevention programs” and put them into the detection and continuing treatment of those specific conditions so often responsible for suicide.

Let’s break that down.

There are some basic demographics that contribute to risk. These are older and male. This does not help us.

Then there are all the social factors that increase risk: poverty, unemployment, social isolation, divorce, living alone, alcoholism, drug addiction, chronic pain. Each of these can only be addressed by specific social programs (minimum wage increase, income equality, safety nets, affordable housing, retraining, community support systems) and focused treatment programs for alcoholism and addictions.

But there are specific high risk groups we can identify and for which we can increase accessible treatment and continuity of care. And these account for the majority of completed suicides. They include:

Recently discharged psychiatric patients.

Unrecognized developing serious mental illness.

Under treated serious mental illness.

Stopping treatment for serious mental illness.

So to put a dent in the actual suicide rate we should be putting our resources in:

Recognizing and making treatment available for Depression, Anxiety, Bipolar disorder, schizophrenia, severe OCD, PTSD (not for or identified by “suicide ideation”)

Providing good continuity of care, especially after discharge from a treatment center.

Using all the tools available including involuntary commitment and community treatment orders to ensure the seriously mentally ill are adequately treated.

Working hard with our patients to keep them in treatment and on medication.

We know, for example, that people with bipolar illness are very high risk for suicide when not receiving treatment. We know they continue to pose a risk for suicide when receiving treatment. But a very important study found this: Those with bipolar illness who were thought to be receiving treatment and who still killed themselves, were found, at autopsy, to not have psychiatric drugs in their systems. They had all stopped treatment.